Background: Adults with sickle cell disease (SCD) seeking treatment for vaso-occlusive crises (VOCs) often encounter barriers based on health care provider (HCP) concerns regarding opioid abuse and addiction. Consensus treatment guidelines for painful VOCs in SCD patients (pts) call for prompt and adequate analgesic use, including opioids and individualized treatment regimens when available. Herein, we evaluate common HCP and SCD pt attitudes about acute care management of VOCs in light of opioid use observed in a recent randomized, double-blind, phase 2 study of an experimental treatment for VOCs (rivipansel) in pts with SCD (Telen et al. Blood 2015;125:2656-64).
Methods: A PubMed literature search was used to identify articles (published 2000–2015) describing relationships between SCD pts and HCPs regarding treatment for VOCs. In the phase 2 study (Telen et al), pts requiring hospitalization for VOCs were randomized to rivipansel or placebo; cumulative parenteral opioid use via patient-controlled anesthesia (PCA), time to discharge, and length of hospital stay were secondary outcome measures.
Results: In pt forums and published studies, SCD pts reported disrespect and dismissive attitudes from HCPs when seeking acute treatment of VOCs, including assessment and treatment delays, often being regarded as a drug addict/abuser. When describing SCD pts who are frequent hospital users, HCPs were skeptical about pt-reported pain severity and viewed opioid-seeking behavior as evidence of addiction. Oppositional attitudes frequently resulted in disputes over drug dosing, pain severity, and readiness for discharge. However, in the phase 2 study, mean opioid use in rivipansel-treated pts was 83% less than in placebo pts (P=0.01), despite access to opioids via PCA. Mean (SD) time to discharge (124.9 [129.6] vs 175.3 [149.6] hours, respectively) and length of hospital stay (132.4 [129.8] vs 183.2 [148.3] hours, respectively) were shorter for rivipansel-treated pts than for placebo pts (Telen et al).
Conclusions: Reduced opioid use and willingness to forgo available opioids in rivipansel-treated pts strongly suggest that pts presenting with VOC requesting opioids is consistent with pseudoaddiction (opioid seeking in response to undertreated pain) and that high levels of opioid use in SCD pts during VOCs are due to medical need for analgesia and possibly tolerance and faster clearance, rather than abuse or addiction (compulsive nonmedical opioid use with impaired control and disregard for adverse effects). Appropriate pain management may also provide additional clinically meaningful benefits, such as shorter time to discharge and decreased length of hospital stay. HCPs should follow consensus guidelines for VOC treatment (including reliance on pt report as the only valid measure of pain severity) and distinguish addiction from pseudoaddiction and tolerance, which are expected physiologic consequences of long-term opioid use.